Cost-effectiveness of WEB Embolization, Coiling and Stent-assisted Coiling for the Treatment of Unruptured Intracranial Aneurysms.

PURPOSE: Information about the cost-effectiveness of a certain treatment is relevant for decision-making and healthcare providers. This study compares the cost-effectiveness of the novel Woven Endobridge (WEB) for intracranial aneurysm treatment with conventional coiling and stent-assisted coiling (SAC) from the perspective of the German Statutory Health Insurance. METHODS: A patient-level simulation was constructed to simulate 55-year-old patients with an unruptured middle cerebral artery aneurysm (size: 3-11 mm) considering WEB treatment, coiling or SAC in terms of morbidity, angiographic outcome, retreatment, procedural and rehabilitation costs and rupture rates. Incremental cost-effectiveness ratios (ICERs) were calculated as costs per quality-adjusted life years (QALYs) and costs per year with neurologic morbidity avoided. Uncertainty was explored with deterministic and probabilistic sensitivity analyses. The majority of data were obtained from prospective multi-center studies and meta-analyses of non-randomized studies. RESULTS: In the base case, lifetime QALYs were 13.24 for the WEB, 12.92 for SAC and 12.68 for coiling. Lifetime costs were 20,440 € for the WEB, 23,167 € for SAC, and 8200 € for coiling. Compared to coiling, the ICER for the WEB was 21,826 €/QALY, while SAC was absolutely dominated by WEB. Probabilistic sensitivity analysis revealed that at a willingness-to-pay of ≥ 30,000 €/QALY, WEB was the preferred treatment. Deterministic sampling showed that the discount rate, material costs and retreatment rates had the largest impact on the ICERs. CONCLUSION: The novel WEB showed at least comparable cost-effectiveness to SAC for treatment of broad-based unruptured aneurysms. Considering all three modalities, coiling had the least costs; however this modality is often not appropriate for the treatment of wide-necked aneurysms.

Comparative costs and cost-effectiveness of behavioural interventions as part of HIV prevention strategies.

BACKGROUND: Behavioural interventions have been widely integrated in HIV/AIDS social marketing prevention strategies and are considered valuable in settings with high levels of risk behaviours and low levels of HIV/AIDS awareness. Despite their widespread application, there is a lack of economic evaluations comparing different behaviour change communication methods. This paper analyses the costs to increase awareness and the cost-effectiveness to influence behaviour change for five interventions in Benin. METHODS: Cost and cost-effectiveness analyses used economic costs and primary effectiveness data drawn from surveys. Costs were collected for provider inputs required to implement the interventions in 2009 and analysed by 'person reached'. Cost-effectiveness was analysed by 'person reporting systematic condom use'. Sensitivity analyses were performed on all uncertain variables and major assumptions. RESULTS: Cost-per-person reached varies by method, with public outreach events the least costly (US$2.29) and billboards the most costly (US$25.07). Influence on reported behaviour was limited: only three of the five interventions were found to have a significant statistical correlation with reported condom use (i.e. magazines, radio broadcasts, public outreach events). Cost-effectiveness ratios per person reporting systematic condom use resulted in the following ranking: magazines, radio and public outreach events. Sensitivity analyses indicate rankings are insensitive to variation of key parameters although ratios must be interpreted with caution. CONCLUSION: This analysis suggests that while individual interventions are an attractive use of resources to raise awareness, this may not translate into a cost-effective impact on behaviour change. The study found that the extensive reach of public outreach events did not seem to influence behaviour change as cost-effectively when compared with magazines or radio broadcasts. Behavioural interventions are context-specific and their effectiveness influenced by a multitude of factors. Further analyses using a quasi-experimental design would be useful to programme implementers and policy makers as they face decisions regarding which HIV prevention activities to prioritize.

Cost effectiveness of secondary vs tertiary prevention for post-menopausal osteoporosis.

BACKGROUND: The aging of the population is likely to increase the number of osteoporosis-related fractures, such as hip fractures, and hence the economic burden for society. Therefore, strategies to identify women at increased risk are of major interest. OBJECTIVE: The aim of this study was to determine the cost effectiveness of preventive services for osteoporosis, comparing secondary plus tertiary prevention (SP/TP) versus tertiary prevention (TP) alone in post-menopausal women in Germany. METHODS: A cost-utility analysis and a budget-impact analysis were performed from the perspective of the German statutory health insurance (SHI). A Markov model simulated costs and benefits discounted at 3% over a lifetime horizon. RESULTS: Cost effectiveness of TP compared with no screening was 669 Euros, 477 Euros and 385 Euros per QALY for women aged 60, 70 and 80 years, respectively (year 2010 values). In women aged 50 years, TP dominated no prevention. Cost effectiveness of SP/TP compared with TP was 4543 Euros, 19791 Euros, 8670 Euros and 3368 Euros for women aged 50, 60, 70 and 80 years, respectively. SP/TP resulted in additional costs of 109 million Euros or 0.10% of the SHI's annual budget (TP alone = 8 million Euros). CONCLUSION: Compared with TP, a strategy based on SP/TP appears to be more expensive but more effective in each age group. Given that cost effectiveness seems acceptable, allocation of resources to SP/TP to decrease post-menopausal osteoporotic fracture risk may be justified.

Evaluation of the Capilia TB assay for culture confirmation of Mycobacterium tuberculosis infections in Zambia and South Africa.

The performance and cost of the Capilia TB assay were evaluated for use in a resource-limited setting. The sensitivity and specificity were 99.6% and 99.5%, respectively. The incremental costs of the Capilia test were estimated to be $1.46 and $1.84 when the test was added to liquid and solid culture processes, respectively. These findings suggest that the Capilia TB assay represents a rapid, simple, and inexpensive Mycobacterium tuberculosis identification test that can be used in resource-limited settings.

Quantitative assessment of stenosis severity and atherosclerotic plaque composition using 256-slice computed tomography.

OBJECTIVE: To quantitatively estimate lumen narrowing and to assess the volume and composition of atherosclerotic plaque with 256-slice computed tomography angiography (CTA), using conventional quantitative coronary angiography (QCA) as the gold standard. METHODS: Twenty-seven consecutive patients with suspected coronary artery disease (CAD) underwent 256-slice CTA and subsequent coronary angiography within 4 weeks. Quantification of lumen narrowing was performed on curved multiplanar reformatted CTA images, in identical projections to those used for QCA. Atherosclerotic plaque volume and composition were assessed by using commercially available software. RESULTS: The overall correlation between the stenosis severity by QCA compared with CTA was high (r(2) = 0.79, p < 0.001). For the detection of >or=50% and >or=75% diameter lesions, CTA yielded high sensitivity, specificity and accuracy (86%, 95% and 90%; and 89%, 100% and 96%, respectively), using QCA as the standard reference. Furthermore, assessment of atherosclerotic plaque yielded highly reproducible results (inter-observer and intra-variability of 13% and 9%, respectively, for the assessment of plaque volume, and high agreement between observers (kappa = 0.86) for the differentiation between non-calcified, mixed and calcified plaque). CONCLUSIONS: Clinically indicated 256-slice CT angiography in symptomatic patients can aid both quantification of lumen narrowing and evaluation of atherosclerotic plaque, with high reproducibility.

Cost-effectiveness of using clinical risk factors with and without DXA for osteoporosis screening in postmenopausal women.

BACKGROUND: According to several guidelines, the assessment of postmenopausal fracture risk should be based on clinical risk factors (CRFs) and bone density. Because measurement of bone density by dual x-ray absorptiometry (DXA) is quite expensive, there has been increasing interest to estimate fracture risk by CRFs. OBJECTIVE: The aim of this study was to determine the cost-effectiveness of osteoporosis screening of CRFs with and without DXA compared with no screening in postmenopausal women in Germany. METHODS: A cost-utility analysis and a budget-impact analysis were performed from the perspective of the statutory health insurance. A Markov model simulated costs and benefits discounted at 3% over lifetime. RESULTS: Cost-effectiveness of CRFs compared with no screening is euro4607, euro21,181, and euro10,171 per quality-adjusted life-year (QALY) for 60-, 70-, and 80-year-old women, respectively. Cost-effectiveness of DXA plus CRFs compared with CRFs alone is euro20,235 for 60-year-old women. In women above the age of 70, DXA plus CRFs dominates CRFs alone. DXA plus CRFs results in annual costs of euro175 million, or 0.4% of the statutory health insurance's annual budget. CONCLUSION: Funders should be careful in adopting a strategy based on CRFs alone instead of DXA plus CRFs. Only if DXA is not available, assessing CRFs only is an acceptable option in predicting a woman's risk of fracture.

Costs of early detection systems for epidemic malaria in highland areas of Kenya and Uganda.

BACKGROUND: Malaria epidemics cause substantial morbidity and mortality in highland areas of Africa. The costs of detecting and controlling these epidemics have not been explored adequately in the past. This study presents the costs of establishing and running an early detection system (EDS) for epidemic malaria in four districts in the highlands of Kenya and Uganda. METHODS: An economic costing was carried out from the health service provider's perspective in both countries. Staff time for data entry and processing, as well as supervising and coordinating EDS activities at district and national levels was recorded and associated opportunity costs estimated. A threshold analysis was carried out to determine the number of DALYs or deaths that would need to be averted in order for the EDS to be considered cost-effective. RESULTS: The total costs of the EDS per district per year ranged between US$ 14,439 and 15,512. Salaries were identified as major cost-drivers, although their relative contribution to overall costs varied by country. Costs of relaying surveillance data between facilities and district offices (typically by hand) were also substantial. Data from Uganda indicated that 4% or more of overall costs could potentially be saved by switching to data transfer via mobile phones. Based on commonly used thresholds, 96 DALYs in Uganda and 103 DALYs in Kenya would need to be averted annually in each district for the EDS to be considered cost-effective. CONCLUSION: Results from this analysis suggest that EDS are likely to be cost-effective. Further studies that include the costs and effects of the health systems' reaction prompted by EDS will need to be undertaken in order to obtain comprehensive cost-effectiveness estimates.

Costs and consequences of large-scale vector control for malaria.

BACKGROUND: Five large insecticide-treated net (ITN) programmes and two indoor residual spraying (IRS) programmes were compared using a standardized costing methodology. METHODS: Costs were measured locally or derived from existing studies and focused on the provider perspective, but included the direct costs of net purchases by users, and are reported in 2005 USD. Effectiveness was estimated by combining programme outputs with standard impact indicators. FINDINGS: Conventional ITNs: The cost per treated net-year of protection ranged from USD 1.21 in Eritrea to USD 6.05 in Senegal. The cost per child death averted ranged from USD 438 to USD 2,199 when targeting to children was successful.Long-lasting insecticidal nets (LLIN) of five years duration: The cost per treated-net year of protection ranged from USD 1.38 in Eritrea to USD 1.90 in Togo. The cost per child death averted ranged from USD 502 to USD 692.IRS: The costs per person-year of protection for all ages were USD 3.27 in KwaZulu Natal and USD 3.90 in Mozambique. If only children under five years of age were included in the denominator the cost per person-year of protection was higher: USD 23.96 and USD 21.63. As a result, the cost per child death averted was higher than for ITNs: USD 3,933-4,357. CONCLUSION: Both ITNs and IRS are highly cost-effective vector control strategies. Integrated ITN free distribution campaigns appeared to be the most efficient way to rapidly increase ITN coverage. Other approaches were as or more cost-effective, and appeared better suited to "keep-up" coverage levels. ITNs are more cost-effective than IRS for highly endemic settings, especially if high ITN coverage can be achieved with some demographic targeting.

Costs and cost-effectiveness of delivering intermittent preventive treatment through schools in western Kenya.

BACKGROUND: Awareness of the potential impact of malaria among school-age children has stimulated investigation into malaria interventions that can be delivered through schools. However, little evidence is available on the costs and cost-effectiveness of intervention options. This paper evaluates the costs and cost-effectiveness of intermittent preventive treatment (IPT) as delivered by teachers in schools in western Kenya. METHODS: Information on actual drug and non-drug associated costs were collected from expenditure and salary records, government budgets and interviews with key district and national officials. Effectiveness data were derived from a cluster-randomised-controlled trial of IPT where a single dose of sulphadoxine-pyrimethamine and three daily doses of amodiaquine were provided three times in year (once termly). Both financial and economic costs were estimated from a provider perspective, and effectiveness was estimated in terms of anaemia cases averted. A sensitivity analysis was conducted to assess the impact of key assumptions on estimated cost-effectiveness. RESULTS: The delivery of IPT by teachers was estimated to cost US$ 1.88 per child treated per year, with drug and teacher training costs constituting the largest cost components. Set-up costs accounted for 13.2% of overall costs (equivalent to US$ 0.25 per child) whilst recurrent costs accounted for 86.8% (US$ 1.63 per child per year). The estimated cost per anaemia case averted was US$ 29.84 and the cost per case of Plasmodium falciparum parasitaemia averted was US$ 5.36, respectively. The cost per case of anaemia averted ranged between US$ 24.60 and 40.32 when the prices of antimalarial drugs and delivery costs were varied. Cost-effectiveness was most influenced by effectiveness of IPT and the background prevalence of anaemia. In settings where 30% and 50% of schoolchildren were anaemic, cost-effectiveness ratios were US$ 12.53 and 7.52, respectively. CONCLUSION: This study provides the first evidence that IPT administered by teachers is a cost-effective school-based malaria intervention and merits investigation in other settings.

Cost effectiveness of the German screen-and-treat strategy for postmenopausal osteoporosis.

BACKGROUND: The German osteology umbrella organization, Dachverband Osteologie (DVO), has published a new guideline for the secondary prevention of osteoporotic fractures. According to the guideline, women are screened using dual x-ray absorptiometry (DXA). Those with an absolute 10-year fracture risk > or =30% are treated with bisphosphonates such as alendronate or risedronate for 4 years or with teriparatide for 18 months. OBJECTIVE: To determine the cost effectiveness of the screen-and-treat strategy versus no intervention in women of the general population aged 50-90 years in Germany. METHODS: Cost-utility and budget-impact analyses were performed from the perspective of the statutory health insurance (SHI). A Markov model with a 1-year cycle length simulated costs and benefits (QALYs), discounted at 3%, over a lifetime horizon. The number of women correctly diagnosed by pre-tests and DXA as having a 10-year fracture risk of > or =30% was estimated for different age groups (50-60, 60-70, 70-80 and 80-90 years). Incremental cost-effectiveness ratios (ICERs) were calculated; all costs are presented in euro, year 2006 values. Robustness of the results was tested by a probabilistic Monte Carlo simulation. RESULTS: Alendronate was the most cost-effective drug in all age groups; the ICERs were euro 3849, euro 16 589, euro 6600 and euro 2337 per QALY for 50-, 60-, 70- and 80-year-old women, respectively, followed by risedronate. Teriparatide was dominated in every age group. Implementing the screen-and-treat strategy would result in annual costs of euro 175 million for alendronate (euro 181 million for risedronate) or 0.14% of the SHI annual budget. Results were robust in the sensitivity analysis. CONCLUSION: While the screen-and-treat strategy would result in a substantial cost increase for the SHI, the use of alendronate within such a strategy appears cost effective when compared with many generally accepted medical interventions.

Cost-effectiveness analysis of insecticide-treated net distribution as part of the Togo Integrated Child Health Campaign.

BACKGROUND: To evaluate the cost-effectiveness of the first nationwide delivery of long-lasting insecticide-treated nets (LLITNs) as part of the 2004 measles vaccination campaign in Togo to all children between nine months and five years. METHODS: An incremental approach was used to calculate the economic costs and effects from a provider perspective. Effectiveness was estimated in terms of malaria cases averted, deaths averted and Disability-Adjusted Life Years (DALYs) averted. Malaria cases were modelled using regional estimates. Programme and treatment costs were derived through reviews of financial records and interviews with key stakeholders. Uncertain variables were subjected to a univariate sensitivity analysis. RESULTS: Assuming equal attribution of shared costs between the LLITN distribution and the measles vaccination, the net costs per LLITN distributed were 4.41 USD when saved treatment costs were taken into account. Assuming a constant utilization of LLITNs by the target group over three years, 1.2 million cases could be prevented at a net cost per case averted of 3.26 USD. The net costs were 635 USD per death averted and 16.39 USD per DALY averted, respectively. CONCLUSION: The costs per case, death and DALY averted are well within commonly agreed benchmarks set by other malaria prevention studies. Varying transmission levels are shown to have a significant impact on cost-effectiveness ratios. Results also suggest that substantial efficiency gains may be derived from the joint delivery of vaccination campaigns and malaria interventions.

Cost effectiveness of ultrasound and bone densitometry for osteoporosis screening in post-menopausal women.

BACKGROUND: According to a new German guideline, decisions about bisphosphonate treatment for post-menopausal women should be based on 10-year fracture risk, and bone density should be measured by dual x-ray absorptiometry (DXA). Recently, there has been growing interest in quantitative ultrasound (QUS) as a less expensive screening alternative. OBJECTIVE: To determine the cost effectiveness of osteoporosis screening with QUS as a pre-test for DXA and treatment with alendronate compared with (i) immediate access to DXA and (ii) no screening in women of the general population aged 50-90 years in Germany. METHODS: A cost-utility analysis and a budget impact analysis were performed from the perspective of the statutory health insurance (SHI). A Markov model with a 1-year cycle length was used to simulate costs and benefits (QALYs), discounted at 3% per annum, over a lifetime. The number of women correctly diagnosed by QUS and DXA as being above a 10-year risk of > or =30% was estimated for different age groups (50-60, 60-70, 70-80 and 80-90 years, respectively). The robustness of the results was tested by a probabilistic Monte Carlo simulation. RESULTS: Compared with no screening, the cost effectiveness of QUS plus DXA was found to be Euro 3529, Euro 9983, Euro 4382 and Euro 1987 per QALY for 50-, 60-, 70- and 80-year-old women, respectively (year 2006 values). This screening strategy results in annual costs of Euro 96 million or 0.07% of the SHI's annual budget. The cost effectiveness of DXA alone compared with DXA plus QUS is Euro 5331, Euro 60, 804, Euro 14, 943 and Euro 3654 per QALY for 50-, 60-, 70- and 80-year-old women, respectively. DXA alone results in a higher number of QALYs in all age groups. The results were robust in the sensitivity analysis. CONCLUSION: Compared with no screening, the cost effectiveness of QUS and DXA in sequence is very favourable in all age groups. However, direct access to DXA is also a cost-effective option, as it increases the number of QALYs at an acceptable cost compared with pre-testing by QUS (except for women aged 60-70 years). Therefore, QUS as a pre-test for DXA can be clearly recommended only in women aged 60-70 years. For the other age groups, the cost effectiveness of QUS as a pre-test depends on the global budget constraint and the accessibility of DXA.

Countdown to 2015: tracking donor assistance to maternal, newborn, and child health.

BACKGROUND: Timely reliable data on aid flows to maternal, newborn, and child health are essential for assessing the adequacy of current levels of funding, and to promote accountability among donors for attainment of the Millennium Development Goals (MDGs) for child and maternal health. We provide global estimates of official development assistance (ODA) to maternal, newborn, and child health in 2003 and 2004, drawing on data reported by high-income donor countries and aid agencies to the Organisation for Economic Development and Cooperation. METHODS: ODA was tracked on a project-by-project basis to 150 developing countries. We applied a standard definition of maternal, newborn, and child health across donors, and included not only funds specific to these areas, but also integrated health funds and disease-specific funds allocated on a proportional distribution basis, using appropriate factors. FINDINGS: Donor spending on activities related to maternal, newborn, and child health was estimated to be US1990 million dollars in 2004, representing just 2% of gross aid disbursements to developing countries. The 60 priority low-income countries that account for most child and newborn deaths received 1363 million dollars, or 3.1 dollars per child. Across recipient countries, there is a positive association between mortality and ODA per head, although at any given rate of mortality for children aged younger than 5 years or maternal mortality, there is significant variation in the amount of ODA per person received by developing countries. INTERPRETATION: The current level of ODA to maternal, newborn, and child health is inadequate to provide more than a small portion of the total resources needed to reach the MDGs for child and maternal health. If commitments are to be honoured, global aid flows will need to increase sharply during the next 5 years. The challenge will be to ensure a sufficient share of these new funds is channelled effectively towards the scaling up of key maternal, newborn, and child health interventions in high priority countries.

Health financing to promote access in low income settings-how much do we know?

In this article we outline research since 1995 on the impact of various financing strategies on access to health services or health outcomes in low income countries. The limited evidence available suggests, in general, that user fees deterred utilisation. Prepayment or insurance schemes offered potential for improving access, but are very limited in scope. Conditional cash payments showed promise for improving uptake of interventions, but could also create a perverse incentive. The largely African origin of the reports of user fees, and the evidence from Latin America on conditional cash transfers, demonstrate the importance of the context in which studies are done. There is a need for improved quality of research in this area. Larger scale, upfront funding for evaluation of health financing initiatives is necessary to ensure an evidence base that corresponds to the importance of this issue for achieving development goals.